Definition & Overview
Pulmonary endarterectomy (PEA) is a medical procedure that removes the blood clot that blocks the pulmonary artery. The goals are to alleviate right ventricular dysfunction as well as pulmonary hypertension. It can also be performed to reduce pulmonary vascular resistance.
Who Should Undergo and Expected Results?
Pulmonary endarterectomy is indicated for patients with a blood clot in their pulmonary artery. It is a highly complex medical procedure that requires careful selection of patients as well as the surgical team with the right expertise in PEA.
Successful pulmonary endarterectomy can have life-changing effects on patients since it can rid all the symptoms of pulmonary hypertension. The survival rate is also high at 96%. However, the intake of life-long maintenance medicine is needed to prevent new blood clots from coming.
The survival rate has been improving for PEA patients as the medical procedure improves and data around the globe continues to increase. The data includes how surgeons around the globe approached the procedure and the many challenges they encounter as well as collective successes throughout the entire operation.
Studies also show that pre-operative treatments or therapy increase the likelihood of success of the entire surgical operation. This means that appropriate pre-surgical treatment using drug therapy is important to better prepare patients for invasive surgery and increase their chances of avoiding postoperative complications.
How is the Procedure Performed?
Pulmonary endarterectomy is a major surgery that requires the opening of the chest wall through a median sternotomy incision (the surgical incision in the breastbone). Dividing the sternum allows surgeons to gain access to the heart.
It can also be performed with cardiopulmonary bypass. Bypass means that an alternative channel, usually a machine, is created or used in order to improve blood flow to the heart (heart bypass) or lungs (pulmonary bypass) or both (cardiopulmonary bypass) when a coronary or pulmonary artery is blocked or temporarily unable to perform its normal function due to a surgical operation.
Before the surgery, the patient in placed under total circulatory arrest. The procedure involves bringing the body temperature down to 20 degrees Celsius to stop blood circulation and brain function for up to one hour. Such technique is very important because it allows the pulmonary arterial branches to be more visible making it easier for surgeons to work on the problem areas.
Recent operations involving PEA are also video-assisted to better check the interior of the artery and better guide the surgeon. Video-assisted procedures typically offer improved patient outcomes.
Pericardiotomy, or the surgical removal of the pericardium (the membrane that encloses the heart), is performed after median sternotomy. The superior vena cava, or the vein that brings blood from the upper part of the body to the heart is also dissected so that doctors can access the pulmonary artery. When the blood clots in the pulmonary artery become visible, an arteriotomy is performed (opening or cutting the arterial wall).
Patients who have undergone pulmonary endarterectomy have to take warfarin, an anticoagulant drug for the rest of their lives to prevent the formation of new blood clots.
Warfarin drug comes in 1mg, 3mg, and 5mg. Most patients start at 1mg. Surgeons put the patient under medical tests to see the effectiveness of the drug. The test happens every 4 to 8 weeks. The dose of the drug is increased if there are indications that blood clot will form.
To check the effectiveness of warfarin, doctors check the patient’s blood sample and see how it clots as compared to a normal blood. This is expressed in ratio and called the international normalised ratio (INR).
The calculation is simple; if the patient’s blood takes twice the normal time to clot, it means that the patient’s INR is 2. In order to rule out a blood clot in the blood vessels, especially the pulmonary artery, the INR must be between 2 and 3.
Possible Risks and Complications
Pulmonary endarterectomy is a high-risk medical procedure that is associated with life-threatening post-surgical complications.
It is also associated with various risks include bleeding. Warfarin prevents blood clot formation or at least reduces the blood’s ability to clot. With that in mind, patients need to be careful with their daily activities as any injury can result in excessive bleeding or bruising.
Patients must contact their doctor if they experience any of these:
- Excessive or nonstop bleeding from cuts
- Bleeding gums
- Red or dark brown urine
- Increased bleeding among women during periods (could be any form of vaginal bleeding)
Warfarin has contraindications and cannot be taken with other medicines unless prescribed by the surgeon. Other food and food ingredients can also interact with the drug. Thus, patients must check with their surgeon if they plan on taking other types of medications.
Additionally, patients will need to inform their dentist that they are taking warfarin so that any dental procedure is scheduled. The dentist and surgeon will work together as to when is the best time to schedule the dental treatment and temporarily stop the intake of the medication.
European Respiratory Review; “Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary hypertension”; http://err.ersjournals.com/content/24/136/263
ATS Journals; “Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension”;